Heart disease with pregnancy Prof Uma Singh

Incidence of heart disease Varies between 0.1 – 4.0 %, average 1% Mortality due to heart disease has decreased Devpd countries – maternal mortality due to heart disease has increased Pregnancy with heart disease has increased Devpd countries – rheumatic is decreasing Congenital heart disease with pregnancy is also increasing

Hemodynamic changes in normal pregnancy PARAMETERCHANGE (PERCENT) Plasma volume+40 Cardiac output+43 Heart rate+17 Mean arterial pressure+4 Stroke volume+27 Systemic vascular resistance -21 Pulmonary vascular resistance -34

Critical periods Changes start from as – 6weeks Max changes around –30 weeks Intra partum period Just after delivery Second week of puerperium

Pregnancy changes mimic cardiac disease Symptoms – breathlessness, weakness, oedema, syncope Tachycardia Splitting of 1 st hear sound Murmur – systolic, breast bruit Displacement of apex beat – upwards to left

Symptoms of heart disease Progressive dyspnea or orthopnea Nocturnal cough Syncope Chest pain Hemoptysis

Clinical findings of heart disease Cyanosis Clubbing of fingers Persistent neck vein distention Systolic murmur grade 3/6 or greater Diastolic murmur Cardiomegaly Persistent arrythmia Persistent split second sound Pulmonary hypertension

Investigations ECG – cardiac arrhythmias, hypertrophy Echocardiography – cardiac status and structural anomalies X-ray chest – cardiomegaly, vascular prominence Cardiac catheterization - rarely

NYHA (New York Heart Association) Functional grading of heart disease Grade I: No limitation of physical activity- asymptomatic with normal activity Grade II: Mild limitation of physical activity - Symptoms with normal physical activity Grade III: Marked limitation of physical activity - Symptoms with less than normal activity, comfortable at rest Grade IV: Severe limitation of physical activity- symptoms at rest

Classification of Heart Disease according to etiology Congenital – non cynotic ( ASD, VSD, Pulm stenosis, coarctation of aorta), cyanotic (Fallots tetralogy, Eisenmenger’s syndrome) Rheumatic heart disease – MS, MR, AS, AR Cardiomyopathy Ischaemic heart disease Others – conduction defects, syphilitic, thyrotoxic, hypertensive,

Classification of Heart Disease during pregnancy according to risk Low risk ( 0 – 1%) – ASD, VSD, PDA, MS- 1,2, corrected FT Medium risk ( 5 – 15 %) – MS-3,4, MS with atrial fibrillation, AS, uncorrected FT High risk ( 25 – 50%) – PH, Eisenmengers Syndrome, aortic coarctation with valvular involvement, Marfans with aortic involvement

Poor prognostic indicators h/o heart failure, ischaemic attack, stroke Arrhythmias, Base line NYHA class 3 and 4 MV area below 2cm sq, AV area below 1.5 Ejection fraction less than 40%

Additional risk factors Anaemia Infections Hypertension Physical labour Weight gain Multiple pregnancy Caffein, alcohol intake Pain Drugs – tocolytic

Effect of pregnancy on heart disease Worsening of cardiac status CCF, bacterial endocarditis, pulmonary edema, pulmonary embolism, rupture of aneurism No long term effect on basic defect

Effect of heart disease on pregnancy Abortion Preterm labour IUGR Congenital heart disease in baby – 5% Intrauterine fetal demise

Management Requires- High index of suspicion Timely diagnosis Effective management Team Approach- Obstetrician Cardiologist Anesthetist Neonatologist CTV surgeon Nursing Staff

Preconceptional Counseling No pregnancy unless must esp in high risk types Maternal mortality varies directly with functional classification at pregnancy onset Optimal Medical/Surgical treatment pre-pregnancy Counselling- – Maternal & Fetal risks – Prognosis – Social and cost considerations – Hospital delivery- Preferable at tertiary care centre

Medical termination of pregnancy Termination advised in early pregnancy in high risk group only – ( Primary pulmonary Ht, Eisenmenger syndrome, Coarctation of aorta, Marfan syndrome with dilated aortic root) Only in 1 st trim, better before 8 weeks Suction evacuation preferred MTP also carries risk for life

Antenatal care Clear counseling of risk and prognosis ANC every 2 weeks upto 30 weeks then weekly On each visit-note-pulse rate, BP, cough dyspnea, weight, anaemia, auscultate lung bases, re- evaluate functional grade Ensure treatment compliance Exclude fetal congenital anomaly by level-III USG and fetal ECHO at 20 weeks in maternal congenital heart disease Fetal monitoring

Special Advice Rest, Avoid undue excitement/strain Diet/ Iron and vitamins Hygiene, dental care to prevent any infection Dietary salt restriction (4-6g/d) Avoid smoking, drugs – betamimetics Early diag and tmt of PIH, infections Therapeutic/prophylactic cardiac interventions as applicable- – Benzathine Penicillin 12 lacs at 3 weeks - to prevent recurrence of rheumatic fever – Diuretics, Beta Blockers, Digitalis, Anticoagulants – Surgical treatment as applicable - balloon mitral valvotomy

Indications for admission Elective admission- NYHA 1 – 2 weeks before EDD NYHA 2 – 28 to 30 weeks NYHA-III/IV- Irrespective of POG as soon as patient comes To Change from oral anticoagulants to heparin-early pregnancy, 36 weeks in patients on anticoagulant Emergency admission- Deterioration of functional grade Symptoms and signs of complications- Fever/ persistent cough/ basal crepts/ tachyarrhythias (P/R >100 min)/ JVP>2cm/Anaemia/ Infections/ PET/Abnormal weight gain /other medical disorders

Labor and Management Institutional delivery Induction of Labor – Only for obstetric indications – Oxytocin preferred- Higher concentration with restricted fluid – Intracervical foley instillation esp in congenital heart disease – PGE 2 Gel may be employed- Vasodilatation - use with caution

Management in first stage of labor Confined to bed- propped up or semi recumbent Intermittent oxygen inhalation 5-6 l/min Sedation and analgesia- (Epidural, pethidine, tramadol) Cautious use of I.V. fluids (not >75ml/hr except in aortic stenosis and VSD) Stop anticoagulants Digitalise if in CHF,P.R.>110/ min, R/R >24/min

Management in first stage of labor Diuretics in pulmonary congestion Deriphyllin if bronchospasm Prevention of infective endocarditis Cardiac monitoring and pulse oximetry ±pulmonary artery catheterisation- continuous haemodynamic monitoring Evaluation by Anaesthetist and cardiologist

SABE Prophylaxis Prophylaxis Not recommended for all At risk for infection At risk for infection Severe lesions Severe lesions Ampicillin-2G IV/IM + Gentamicin 1.5mg/kg (max120) 6 hours later- Ampicillin-1G I.V./IM or 1G P.O. Ampicillin-2G IV/IM + Gentamicin 1.5mg/kg (max120) 6 hours later- Ampicillin-1G I.V./IM or 1G P.O. If Allergic to Penicillin - Vancomycin-1G I.V. or Clindamycin – 600mg IV If Allergic to Penicillin - Vancomycin-1G I.V. or Clindamycin – 600mg IV + Gentamicin-1.5mg/kg + Gentamicin-1.5mg/kg

Management of second stage of labor Delivery in propped up position Avoid forceful bearing down Adequate pain relief-epidural/pudendal block avoid spinal/Saddle block Cut short second stage of labor- episiotomy, vacuum, forceps – not always must Strict Cardiovascular monitoring

Third stage of labor- AMTSL-10 U oxytocin IMI Avoid bolus syntocinon/Ergometrine Propped Up, oxygen inhalation Furosemide I.V. 40 mg Pethidine/morphine (15mg) Watch for signs of CHF & Pul. Edema Treat PPH energetically

First Hour After Delivery Propped up/sitting position, oxygen Watch for signs of pulm edema Sedation Antibiotics

Indications for LSCS- Mainly obstetrical Coarctation of aorta Marfan syndrome with dilated root of aorta – Prefer epidural anaesthesia – Narcotic conduction analgesia/GA in Pulmonary hypertension and pts having intracardiac shunts

Advice at time of discharge: Continue medical treatment Avoid infection Reassesment after 6 weeks or earlier if some complication occurs Iron supplementation Cardiological consultation for definitive management of heart disease

Contraceptive advice at time of discharge: Contraception- Barrier, Progesterone – good option- DMPA, Norplant IUCD-Less preferred COC - contraindicated Sterilization- vasectomy-best Tubal ligation-Interval, puerperial can be done

MCQs Text book of Obstetrics, Dr J B Sharma, 1 st edition Page 529 to 536

1. Pregnancy is contra indicated with Mitral stenosis Aortic stenosis Fallots tetralogy Eisenmengers syndrome

2. Pregnancy is contra indicated with Mitral stenosis Aortic stenosis Fallots tetralogy Eisenmengers syndrome

2. Third stage of labour in a case of heart disease should be managed by Ergometrine Oxytocin Misoprostol Carboprost

Third stage of labour in a case of heart disease should be managed by Ergometrine Oxytocin Misoprostol Carboprost

3. In pregnancy with heart disease risk of cardiac failure increases at weeks weeks weeks weeks

3. In pregnancy with heart disease risk of cardiac failure increases at weeks weeks weeks weeks

4. A pregnant women suffering from heart disease gets breathless on doing minimal activity but is comfortable at rest. Her cardiac function status is NYHA Class 1 NYHA Class 2 NYHA Class3 NYHA Class 4

4. A pregnant women suffering from heart disease gets breathless on doing minimal activity but is comfortable at rest. Her cardiac function status is NYHA Class 1 NYHA Class 2 NYHA Class3 NYHA Class 4

5. Which of the following contraceptive is contraindicated in a woman with heart disease? OCP POP Lng IUS Diaphragm

5. Which of the following contraceptive is contraindicated in a woman with heart disease? OCP POP Lng IUS Diaphragm

6. A 24 year old pregnant Gr2 P1 woman, having prosthetic valve was being given warfarin. She should be switched to heparin at a) 32 weeks b) 36 weeks c) 40 weeks d) at onset of labour

6. A 24 year old pregnant Gr2 P1 woman, having prosthetic valve was being given warfarin. She should be switched to heparin at a) 32 weeks b) 36 weeks c) 40 weeks d) at onset of labour

7. A pregnant woman suffering from mitral stenosis is breathless even when lying down. Her NYHA cardiac function status is a) class 1 b) class 2 c) class 3 d ) class 4

7. A pregnant woman suffering from mitral stenosis is breathless even when lying down. Her NYHA cardiac function status is a) class 1 b) class 2 c) class 3 d ) class 4